Avoiding Errors in Health Insurance Claims
Part 1: The Basic Tools, Chapter 3: Developing a Systematic Approach to Dealing with Health Insurance Page 10
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For example, I once sent eight bills to an insurer with a single claim form. All of the bills were for prescription medications, and they totaled $600. The insurance policy I had at that time provided reimbursement for prescription medications at the 80% rate (an 80/20 plan) under major medical. I knew that I had already met the deductible for the year, and I therefore expected $480 in reimbursement. The insurance company check, however, was for less than $400.
Since I had sent the bills in together, attached to a single claim form, the EOBS listed only the total amount of the claim and the reimbursement amount. There was no indication of which bills were paid and which were not. Under the section labeled "Provider" on the EOBS, it just said "Prescriptions.' It took almost an hour on the telephone with an insurance company representative to review the bills individually and to make sense of the reimbursement provided by the insurer.
Fortunately, it turned out to be a simple error. The insurer had mistakenly decided that two of the bills were duplicates and had paid only seven bills instead of eight. Although I eventually received full reimbursement for the eighth bill, sorting out the problem required a great deal of work. If I had sent the bills in individually -- a few days apart -- with a separate claim form for each bill, they would have been processed separately. I would then have received a separate EOBS for each claim, and I would have been able to identify the error immediately.
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